Acute GI bleed

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    21-Jan-2018
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Transcript of Acute GI bleed

  1. 1. Scenario A 72-year-old woman presents to the emergency room after 2 episodes of coffee-ground emesis and a 1-day history of melena. She has no other gastrointestinal (GI) symptoms. She complains of dizziness when standing, but denies shortness of breath and chest pain. She has a history of hypertension, diabetes, and coronary artery disease. Three weeks ago, she sustained a myocardial infarction and had 3 stents placed. She takes insulin, metformin, metoprolol, aspirin, and clopidogrel. Her heart rate is 98,blood pressure is 135/80 The physical examination is unremarkable except for melenic stool on rectal examination. Relevant laboratory values include a hemoglobin level of 8.1, platelet count of 215, blood urea nitrogen level of 38, creatinine level of 1.2, and a normal INR.
  2. 2. Acute GI Bleeding Romeo Mathew MSc Nursing 2nd year Manipal College of nursing, Manipal
  3. 3. Outline 1. Meaning 2. Etiology 3. Diagnostic History 4. Physical Examination 5. Interpretation of Findings 6. Pathophysiology with symptoms 7. Diagnosis 8. Treatment 9. Nursing Management 10. Risk Stratification
  4. 4. Meaning Gastrointestinal (GI) bleeding refers to any bleeding that starts in the gastrointestinal tract
  5. 5. Meaning Bleeding may come from any site along the GI tract, but is often divided into: Upper GI bleeding: The upper GI tract includes the esophagus (the tube from the mouth to the stomach), stomach, and first part of the small intestine. Lower GI bleeding: The lower GI tract includes much of the small intestine, large intestine or bowels, rectum, and anus.
  6. 6. Etiology GI bleeding may be due to conditions including: Anal fissure Hemorrhoids Cancer of the colon Cancer of the small intestine Cancer of the stomach Intestinal polyps (a pre-cancerous condition)
  7. 7. Upper GI tract disorders Peptic Ulcer Disease Duodenal ulcer (2030%) Gastric ulcer (1020%) Gastric or duodenal erosions (2030%) Varices (1520%)
  8. 8. Upper GI tract disorders Mallory-Weiss tear (510%) Erosive esophagitis (510%) Hemangioma (510%) Arteriovenous malformations (< 5%)
  9. 9. Lower GI tract disorders Anal fissures Angiodysplasia (vascular ectasia) Colitis: Radiation, ischemic, infectious Colonic carcinoma Colonic polyps
  10. 10. Lower GI tract disorders Diverticular disease Inflammatory bowel diseases: Ulcerative proctitis/colitis, Crohn disease Internal hemorrhoids
  11. 11. Diagnostic History History of present illness should attempt to ascertain quantity and frequency of blood passage Quantity can be difficult to assess because even small amounts (5 to 10 mL) of blood turn water in a toilet bowl an opaque red, and modest amounts of vomited blood appear huge to an anxious patient Patients with hematemesis should be asked whether blood was passed with initial vomiting or only after an initial (or several) non-bloody emesis.
  12. 12. Patients with rectal bleeding : whether pure blood was passed/was mixed with stool, pus, or mucus; or whether blood simply coated the stool. Those with bloody diarrhea should be asked about travel or other possible exposure to GI pathogens Past medical history : previous GI bleeding (diagnosed or undiagnosed); known inflammatory bowel disease, bleeding diatheses, and liver disease; and use of any drugs that increase the likelihood of bleeding or chronic liver disease (eg, alcohol).
  13. 13. Medication history A thorough medication history should be obtained, with particular attention paid to drugs that predispose to peptic ulcer formation, such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) Promote bleeding, such as antiplatelet agents (eg:Clopidogrel) and anticoagulants May alter the clinical presentation, such as bismuth and iron, which can turn the stool black
  14. 14. Physical examination General examination focuses on vital signs and other indicators of shock or hypovolemia (eg:Tachycardia, tachypnea, pallor, diaphoresis, oliguria, confusion) and anemia (eg:pallor, diaphoresis) Patients with lesser degrees of bleeding may simply have mild tachycardia (heart rate > 100)
  15. 15. Orthostatic changes in pulse (a change of > 10 beats/min) or BP (a drop of 10 mm Hg) often develop after acute loss of 2 units of blood A digital rectal examination is necessary to search for stool color, masses, and fissures. Anoscopy is done to diagnose hemorrhoids. Chemical testing of a stool specimen for occult blood completes the examination if gross blood is not present
  16. 16. Red flags Several findings suggest hypovolemia or hemorrhagic shock: Syncope Hypotension Pallor Diaphoresis Tachycardia
  17. 17. Interpretation of findings The history and physical examination suggest a diagnosis in about 50% of patients, but findings are rarely diagnostic and confirmatory testing is required. Epigastric abdominal discomfort relieved by food or antacids peptic ulcer disease Weight loss and anorexia, with or without a change in stool GI cancer History of cirrhosis or chronic hepatitis : esophageal varices. Dysphagia suggests esophageal cancer or stricture
  18. 18. A history of bleeding(eg:purpura,ecchymosis, hematuria) Bleeding diathesis (eg, hemophilia, hepatic failure) Bloody diarrhea, fever, and abdominal pain Ischemic colitis, inflammatory bowel disease (eg:ulcerative colitis, Crohn disease) or an infectious colitis(eg:Shigella,Salmonella, Campylobacter,amebiasis) Hematochezia diverticulosis or angiodysplasia Fresh blood only on toilet paper or the surface of formed stools Internal hemorrhoids or fissures, whereas blood mixed with the stool indicates a more proximal source Occult blood in the stool First sign of colon cancer or a polyp, particularly in patients > 45 yr.
  19. 19. Vomiting and retching before the onset of bleeding Mallory-Weiss tear of the esophagus Spider angiomas, hepatosplenomegaly, or ascites with chronic liver disease possible esophageal varices. Arteriovenous malformations, especially of the mucous membranes Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome) Cutaneous nail bed and GI telangiectasia may indicate systemic sclerosis or mixed connective tissue disease
  20. 20. Pathophysiology
  21. 21. Diagnosis Abdominal X-ray, CT scan, MRI Angiography Bleeding scan (tagged red blood cell scan) Capsule endoscopy (camera pill that is swallowed to look at the small intestine) Colonoscopy CBC, clotting tests, platelet count, and other laboratory tests Enteroscopy Sigmoidoscopy
  22. 22. CBC, coagulation profile NGT Upper endoscopy for suspected upper GI bleeding Colonoscopy for lower GI bleeding (unless clearly caused by hemorrhoids)
  23. 23. Upper endoscopy (examination of the esophagus, stomach, and duodenum) should be done for upper GI bleeding. Because endoscopy may be therapeutic as well as diagnostic, it should be done rapidly for significant bleeding but may be deferred for 24 h if bleeding stops or is minimal. Angiography is useful in the diagnosis of upper GI bleeding and permits certain therapeutic maneuvers (eg:embolization, vasoconstrictor infusion).
  24. 24. Flexible sigmoidoscopy and anoscopy may be all that is required acutely for patients with symptoms typical of hemorrhoidal bleeding. All other patients with hematochezia should have colonoscopy, which can be done electively after routine preparation unless there is significant ongoing bleeding.
  25. 25. Treatment Airway A major cause of morbidity and mortality in patients with active upper GI bleeding is aspiration of blood with subsequent respiratory compromise. To prevent these problems, endotracheal intubation should be considered in patients who have inadequate gag reflexes or are obtunded or unconsciousparticularly if they will be undergoing upper endoscopy.
  26. 26. Hemostasis : GI bleeding stops spontaneously in about 80% of patients. The remaining patients require some type of intervention. Early intervention to control bleeding is important to minimize mortality, particularly in elderly patients Active variceal bleeding can be treated with endoscopic banding, injection sclerotherapy, or a transjugular intrahepatic portosystemic shunting (TIPS) procedure
  27. 27. Treatment Severe, ongoing lower GI bleeding caused by diverticula or angiomas can sometimes be controlled colonoscopically by electrocautery, coagulation with a heater probe, or injection with dilute epinephrine. Polyps can be removed by snare or cautery. If these methods are ineffective or unfeasible, angiography with embolization or vasopressin infusion may be successful
  28. 28. Treatment : Geriatrics care In the elderly, hemorrhoids and colorectal cancer are the most common causes of minor bleeding. Peptic ulcer, diverticular disease, and angiodysplasia are the most common causes of major bleeding. Variceal bleeding is less common than in younger patients. Massive GI bleeding is tolerated poorly by elderly patients. Diagnosis must be made quickly, and treatment must be started sooner than in younger patients, who can better tolerate repeated episodes of bleeding
  29. 29. GENERAL MANAGEMENT Triage All patients with hemodynamic instability or active bleeding should be admitted to an intensive care unit for resuscitation and close observation with monitoring Other patients can be admitted to a regular medical ward
  30. 30. General support Supplemental oxygen by nasal cannula Nothing by mouth PIVC(16G/18G) or a central venous line should be inserted Placement of a pulmonary artery catheter Elective endotracheal intubation in patients with ongoing hematemesis or altered respiratory or mental status may facilitate endoscopy and decrease the risk of aspiration.
  31. 31. Treatment- Fluid resuscitation Adequate resuscitation and stabilizatio